Question:
Tricare Prime- Need tips for PCM referral!!
I have a bmi of 35, would love to get a lap band, but learned tricare won't cover. Any suggestions on getting approved for another type of wls? I suffer from migranes, have pain in my lower extremeties, family history of diabetes and arthritis, some acid reflux due to gallbladder removal....... any suggestions for my appointment to get him to understand so i don't have to gain more weight just to qualify?? Anyone have suggestions on what type of wls i should ask for? — ratdogshome (posted on September 17, 2007)
September 17, 2007
My first question is have you talked to your PCM. Most are extremely
helpful with requests. Also learn more about the difference surgeries, this
is not something that should be jumped into. Most are total life altering,
in both good and bad ways. I would ask with your bmi so low what is your
starting height weight. Likely your PCM could refer you to a nutritionist
and/or physical therapist to likely help you loose weight.
— Navada L.
September 17, 2007
You seem to be buried between a rock and a hard place and insurance
companies are very stubborn about BMI's and co-morbidities. You or your
doctor will have to prove at least one co-morbidity in order to qualify.
You should call your insurance company directly and find out if they will
cover lapband or ask your doctor to fight for you. WLS is a cash cow for
surgeons and they will do what they can to get you approved.
— Sheri A.
September 17, 2007
with your prime it may be easier to get the lap band at your base. is
that something they do there, or would you have to go elsewhere?
When I first looked into WLS, I had to get referred out because our
instalation did not do that. Surgeon suggested I get the lap band (which
is what I wanted anyway), but Tricare denied it. Three months later we
moved to Ohio, (WPAFB) they actually do the procedure and I got approved
within weeks.
Also, as stated your height and actual weight is important. If I recall
correctly, if your BMI is <35, you do have to have other weight related
medical issues (mine was hypertension)
— edeelynn
September 17, 2007
I am pre-surgery. I started with a BMI of 37.5 and now how a BMI of 34.5
awaiting surgery within a few weeks (some medical complications). I am
qualified by co-morbidities even though I am at the lower range BMI.
Discuss your co-morbidities with him. If that doesn't resonate, get a
second opinion. Search for the truth of your situation and make sure you
have a good internist to guide you.
Best of luck.
— [Deactivated Member]
September 18, 2007
Hi! Well, here's my story. I approached my PCM in January. My particular
PCM is not a 'surgical' support doc. So I asked to see another doc at the
base, I was first reffered to a endocronoligist. And then I pushed. I have
found that with Tricare if you push for what you want... things get done...
So. get all your co-morbities listed, all the diets and weightloss plans
that you have tried listed, reasearch your surgery or procedure that you
would like done... and then approach your PCM with everything in hand. Show
him/her that you are educated, and ready for the decision that you have
made. Then get a refferal to a gastric doc. Most PCM's don't want to waste
time or money, so make them know that you are firm in your decision. Also,
let them know that it's ultimately not their decsion if you even qualify
for the surgery, it's your gastric doc's. I had the RNY procedure on the
11th of Sept and I am doing great! Best of luck and if you have any more
questions... let me know. OH! Be aware that Tricare will not cover your
nutritionist and that can cost up aroun $500. Bye!
— Jennifer C.
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